PT Kustodian Sentral Efek Indonesia - Post Trade Processing lamp1pendptp

Formulir Pendaftaran Manajer Investasi
Fund Manager Registration Form
A. Data Manajer Investasi

Nomor: _______________
Number

Fund Manager Data
1.

Nama Manajer Investasi
Fund Manager’s name

:

2.

Alamat
Address

:

Kode
Code

*)

:
3.

Kode Pos
Zip Code

:

4.

Kota
City

:

5.

Nomor Telepon
Telephone Number

:

6.

Nomor Faksimili
Fax Number

:

7.

Surat Elektronik
Email Address

:

8.

Pejabat Berwenang 1
1s t Authorized Person

:

9.

No. NPWP
Tax ID Number

:

Pejabat Berwenang 2
2nd Authorized Person

:

10.

Alamat situs perusahaan
Corporate Website Address

:

11.

Bank Pembayar
Payment Bank

:

C. Dokumen*)
Document
1.

Surat Perjanjian KSEI – Manajer Investasi

KSEI – Fund Manager Agreement

6.

Surat kuasa penunjukkan pejabat berwenang dilampiri dengan fotokopi kartu identitas
Power of Attorney – Appointment of Authorized Officials, photocopies of ID cards attached

2.

Fotokopi NPWP
Photocopy of Tax Registration Card

7.

Specimen tandatangan
Specimen of Authorized Officials’ signatures

3.

Fotokopi Akta Pendirian/Anggaran Dasar

Photocopy of Act of Establishment/Article of Association

8.

Alamat Email pejabat berwenang
Authorized Officials’ Email addresses

4.

Surat Keterangan Domisili
Letter of Domicile

5.

Izin Usaha dari Bapepam
Bapepam Business License

D. Pengesahan
Validation
Dengan menandatangani Formulir Pendaftaran Manajer Investasi ini, kami menyatakan telah membaca dan memahami seluruh peraturan KSEI tentang penitipan kolektif di KSEI

serta setuju untuk tunduk dan mematuhi peraturan tersebut.
By signing this Fund Manager Registration Form, we declare that we have read and understood all KSEI regulations regarding collective custody in KSEI, and will abide by and be
subject to such KSEI regulations.
Kami menyatakan bahwa semua keterangan dan dokumen yang kami berikan kepada KSEI adalah lengkap dan benar.
We declare that all information and documents submitted to KSEI are correct and complete.
Jakarta _____/_____/_____

Petugas KSEI
KSEI Officer

(……………………………..….)

(……………………………..….)

(………………………………….)

Nama & Tanda Tangan Pejabat berwenang 1
Name & Signature of 1s t Authorized Official

Nama & Tanda Tangan Pejabat berwenang 2

Name & Signature of 2nd Authorized Official

Nama, Tanda tangan dan Cap
Name, signature and seal

*)

E. Status
1.

Pemeriksaan Dokumen oleh Bagian Hukum 2.
Document Check by Legal Department

(……………………………….)
Nama & Tanda Tangan
Name & Signature
*)
Hanya diisi oleh Petugas KSEI
*)
For KSEI use only

FM-CR-11- 2005 ( 1/ 1), Rev. 0

Input Data
Data Input

(……………………………….)
Nama & Tanda Tangan
Name & Signature

3.

Persetujuan
Approval

(……………………………….)
Nama & Tanda Tangan
Name & Signature